Adverse Childhood Experiences

Adverse Childhood Experiences

A Public Health Nightmare

One sobering illustration of the enormity of the public health problem posed by exposure to toxic stress comes from the Adverse Childhood Experiences Study done by Kaiser Permanente in San Diego and the Centers for Disease Control and Prevention in Atlanta, Georgia (Dietz et al., 1999; Dube, Anda, Felitti, Chapman, et al., 2001; Dube, Anda, Felitti, Croft, et al., 2001; Dube, Anda, Felitti, Edwards, & Williamson, 2002; Edwards, Anda, Felitti, & Dube, 2004; Edwards, Holden, Felitti, & Anda, 2003; Vincent J Felitti et al., 1998). The purpose of the study was to examine the impact of exposure to toxic levels of stress across the life span. So far, this is the largest study of its kind to examine the long-term health and social effects of adverse childhood experiences and included almost 18,000 participants. The researchers asked these willing participants—all members of the Kaiser HMO in San Diego—if they would take a survey. The majority of those who participated were Caucasian, 50 years of age or older, and were well educated, representing a solidly white, middle-class population.

An adversity score or “ACE” score was calculated by simply adding up the number of categories of exposure to a variety of childhood adversities that the person had experienced before the age of 18. These categories included severe physical or emotional abuse; contact sexual abuse; severe emotional or physical neglect; living as a child with a household member who was mentally ill, imprisoned, or a substance abuser; or living with a mother who was being victimized by domestic violence; or parental separation/divorce. So, for example, a client comes for treatment or for some kind of help, and you find out that she was sexually abused by an uncle as a child, her parents were divorced, her mother was hospitalized for depression, and her father drank heavily and used drugs. Her ACE score would be at least “4”—one each for sexual abuse, parental divorce, mental illness in her mother, and substance abuse in her father. Or a client tells you that his father spent time in prison when he was growing up, his mother was a drug addict and neglected him, and his stepfather beat him. His ACE score would be five—score 1 for living with someone as a child who was in prison, another for his mother’s drug addiction, one each for emotional and physical neglect, and one for physical abuse.

Of this largely white, middle-class, older population, almost two-thirds of the participants had an ACE score of one or more, while one in five was exposed to three or more categories of adverse childhood experience (Centers for Disease Control and Prevention, 2006). Two-thirds of the women in the study reported at least one childhood experience involving abuse, violence, or family strife. Once they had gathered this data, the researchers compared the ACE score to each person’s medical, mental health, and social health data. What they found was startling and very disturbing. The higher the ACE score, the more likely a person was to suffer from one of the following: smoking, chronic obstructive pulmonary disease, hepatitis, heart disease, fractures, diabetes, obesity, alcoholism, intravenous drug use, depression and attempted suicide, teen pregnancy, sexually transmitted diseases, poor occupational health, and poor job performance (Middlebrooks & Audage, 2008). Worse yet, the higher the ACE score, the more likely people were to have a number of these conditions interacting with each other. In other words, the higher the ACE score, the greater the impact on a person’s physical, emotional, and social health.

According to the study findings, if you are a woman and have adverse childhood experiences your likelihood of being a victim of domestic violence and rape steadily increases as the ACE score rises and if you are a man, your risk of being a domestic violence perpetrator also rises. The study showed that adverse childhood experiences are surprisingly common, although typically concealed and unrecognized and that ACEs still have a profound effect 50 years later, although now transformed from psychosocial experience into organic disease, social malfunction, and mental illness. The authors of the study concluded, “We found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults” (p. 245) (V. J. Felitti et al., 1998).

A replication of the Adverse Childhood Experiences Study—one that would take into account, for example, the other kinds of exposure that inner-city children have, in addition to the existing categories of adversity —has not yet been attempted. We do know, however, that many children who live in conditions of urban poverty are exposed to dreadful experiences. Surveys done in Detroit, Chicago, Los Angeles, and New Orleans suggest that about a quarter of youth surveyed had witnessed someone shot and/or killed during their lifetime (Bell & Jenkins, 1993; Groves B, Zuckerman B, Marans S, & DJ., 1993; Osofsky, Wewers, Hann, & Fick, 1993; Richters & Martinez, 1993). Among children at a pediatric clinic in Boston, 1 out of every 10 children witnessed a shooting or stabbing before the age of 6 (Groves, Zuckerman B, Marans S, & DJ., 1993). Another group of researchers showed in a 1998 study of 349 low-income black urban children (ages 9–15), that those who witnessed or were victims of violence showed symptoms of posttraumatic stress disorder similar to those of soldiers coming back from war (Li, Howard, Stanton, Rachuba, & Cross, 1998). The Justice Department recent supported the most comprehensive nationwide survey of the incidence and prevalence of children’s exposure to violence to date (Finkelhor, Turner, Ormrod, Hamby, & Kracke, 2009). The findings are extremely disturbing confirming that most of our society’s children are exposed to violence in their daily lives, over 60% in the past year. Nearly half of the children and adolescents had been assaulted at least once in the past year. We have not even begun to reckon with the long-term public health effects of this kind of violence exposure, nor have we addressed that in less than 20 years, the number of children with incarcerated parents has increased by 80% (Glaze & Maruschak, 2008). We have not yet begun to reckon with the fact that one in six black men, as of 2001, had been incarcerated and that if current trends continue, one in three black males born today can expect to spend time in prison during his lifetime (Mauer & King, 2007).

So how fit is our human service delivery system to respond to the overwhelming needs facing it? Not very fit at all. But it gets even more complicated. Remember, the people studied in the Adverse Childhood Experiences Study were 50 years old or older when the study was done in the 1990s. They are now reaching retirement age, so the exposure of children to adversity is not new and cannot be blamed on recent cultural changes. These are people who are in the workforce, who are making the policies, and directing organizations. These are the judges, the police officers, the hospital administrators, the social workers, the Congressmen and women. Many people who are drawn to a social service environment have experienced overwhelming adversity themselves, so let’s look at that for a moment.

Adverse Childhood Experiences and the Workforce Crisis

Given the rate of exposure to adverse childhood experiences in the general population, many of us who work in health care, mental health, child welfare, housing, and other human services are consumers of those services from time to time. And even if we haven’t sought formal assistance, people who work in the social service field are, if anything, more likely to have suffered from childhood adversity. Many people go into this work as a helping professional because of their own struggles with loss and injury.

Several years ago we did a very simple survey of the residential staff at Andrus Children’s Center and found that over 80% of the staff had suffered some form of childhood adversity. In our various training experiences, several of our faculty have asked the participants of the Sanctuary Institute trainings (anonymously of course) about their own experiences of childhood adversity as defined in the ACE Study. Out of 350 human service workers with a wide variety of experience, training, and professional education, 37% said they had been psychologically abused by their parents and 29% said they had been physically abused. When asked about neglect, 35% of them said they had been emotionally neglected, while 12% said they had been physically neglected. A quarter of those surveyed said they had been sexually molested while they were still children. An astonishing 40% said that as children they had lived with someone who was a substance abuser while 41% of them came from broken homes. Over a fifth of them had witnessed domestic violence as children, while 10% of them grew up in households where someone was in prison.

This does not suggest that these social service workers are ill equipped to do their jobs, but it might suggest that they might be prone to having reactions to stress not unlike the clients that they serve. Add to this the reality that the work in residential care and virtually all social service settings is routinely stressful, and it is not always clear who is triggering whom when we unpack incidents. Making the assumption that the clients are the most volatile ingredient in these situations is often wishful thinking.

The issue of childhood adversity is tied to the workforce crisis in social services. There is serious concern for the future in terms of social policy and the impact of exposure to adversity on a significant number of the workforce. As discussed in an article published in the Proceedings of the National Academy of Science: a growing proportion of the U.S. workforce will have been raised in disadvantaged environments that are associated with relatively high proportions of individuals with diminished cognitive and social skills.

A cross-disciplinary examination of research in economics, developmental psychology, and neurobiology reveals a striking convergence on a set of common principles that account for the potent effects of early environment on the capacity for human skill development. Central to these principles are the findings that early experiences have a uniquely powerful influence on the development of cognitive and social skills and on brain architecture and neurochemistry, that both skill development and brain maturation are hierarchical processes in which higher level functions depend on, and build on, lower level functions, and that the capacity for change in the foundations of human skill development and neural circuitry is highest earlier in life and decreases over time. (p. 10155) (Knudsen, Heckman, Cameron, & Shonkoff, 2006).

These findings lead to the conclusion that the most efficient strategy for strengthening the future workforce, both economically and neurobiologically, and improving the quality of life for workers is to invest in the environments of disadvantaged children during the early childhood years (Knudsen et al., 2006).

McEwen, B. S., & Gianaros, P. J. (2010). Central role of the brain in stress and adaptation: Links to socioeconomic status, health, and disease Annals of the New York Academy of Sciences, 1186, 190-222.

National Scientific Council on the Developing Child. (2007a). A Science-Based Framework for Early Childhood Policy: Using Evidence to Improve Outcomes in Learning, Behavior, and Health for Vulnerable Children. . Accesses March 23, 2009, http://www.developingchild.harvard.edu.

National Scientific Council on the Developing Child. (2007b). The Science of Early Childhood Development,. Accessed March 23, 2009, http://www.developingchild.net.

Curriculum

A Trauma-Informed Psychoeducational Group Curriculum

S.E.L.F. represents the four nonlinear, key areas of recovery that provide an organizing framework for the complex problems presented by trauma survivors, by families with problems, and by chronically stressed organizations.

Creating Sanctuary: Toward the Evolution of Sane Societies

Destroying Sanctuary: The Crisis in Human Service Delivery Systems

Restoring Sanctuary: A New Operating System for Trauma-Informed Systems of Care

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Sandra L. Bloom, M.D.Associate Professor, Health Management and Policy, Dornsife School of Public Health, Drexel University

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